Adult History

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Adult History Name:

Age

__

Reason for today's visit?

Audiology/Medical

History

How is your general health?

History of ear disease?

Yes

No

If yes, explain

_

History of hearing loss?

Yes

No

History of noise exposure?

Yes

No

If yes, explain Family history of hearing loss?

Yes

No

If yes, explain

_

Do you have dizziness, vertigo or loss of balance?

_

Have you ever worn a hearing aid? Yes

No

Are you currently employed? If yes, occupation?

No _

Yes

Yes

No

If yes, explain Do you have any tinnitus? [i.e. ringing, buzzing, hissing)

__ Yes

No

If yes, which ear? Right

Left

Recent hospitalizations/surgeries

Yes

__ _

No _

Yes

No

Do you currently smoke or use any other form of tobacco? Yes No Please circle any that apply: Arthritis Cancer (Type _ Chemotherapy Shingles Encephalitis Fatigue

Sincewhen?

What isthe duration?

If yes, explain History of Diabetes?

Both

Howfrequent?

Recurrent Headaches Constant Headaches Head Injury Heart problems High Blood Pressure Malaria

Do you wear a pacemaker?

Measles Meningitis Migraines Mumps Neurofibromatosis Scarlet Fever

Allergic to the following:

updates?

0 0

No

Stroke Typhoid Fever Vascular problems Under aspirin regimen Eyeproblems Neurological symptoms _

Yes Do you agree to receive quarterly educational email/mail Are you on Facebook?

Yes

No

o o

Hearing Difficulty Questionnaire

Listening Situations

Importance

Hearing Quality

to You

(See Key Below) Not

Somewhat

Very

Quiet (one to one conversations

1 2 345

1

2

3

Television

1 2 345

1

2

3

Leisure Activities

1 2 345

1

2

3

Restaurants

1 2 345

1

2

3

Church/Synagogue

1 2 345

1

2

3

Meetings/Groups

1 2 345

1

2

3

Work Place

12345

1

2

3

Telephone

1 2 345

1

2

3

Car

1 2 345

1

2

3

Male Voice

12345

1

2

3

FemaleVoice

1 2 345

1

2

3

Child's Voice

1 2 345

1

2

3

Other(please indicate)

1 2 345

1

2

3

Patient's Signature

1. Always 2. Almost Always 3. Most of the Time 4. Once in a While 5. Hardly ever

Date

Name:

__

List of Current Medications

Name of Medication

Dosage

HowlHow

Often Taken

Reason

Date Started

Prescriber